Top doctor shocked after St George’s hospital destroyed records following death of 20-year-old

Key medical records related to Fitzpatrick’s death were withheld from the family and then destroyed, she said.

“We all know that accidents happen, sometimes things go wrong,” Philippa Fitzpatrick said at the hearing before Assistant Medical Examiner Derek Lee.

“It would have been a lot easier for us as a family to accept what happened and be able to grieve… if we had been told the truth from the start.

“We would have been spared two and a half years trying to figure out what happened.”

The former director of intensive care at St. George’s Hospital, Associate Professor Theresa Jacques, shook her head when cross-examination brought up the destruction of the records.

“I’m just appalled at the family’s experience on the medical records,” she said.

“I couldn’t believe it…I wasn’t aware of it.”

Philippa and Peter Fitzpatrick leave Lidcombe Coroner's Court with their daughters Amanda (left) and Emma on Monday.

Philippa and Peter Fitzpatrick leave Lidcombe Coroner’s Court with their daughters Amanda (left) and Emma on Monday. Credit: James Brickwood

Attorney assisting the coroner, Patrick Rooney, said questions examined at the inquest included when and how Fitzpatrick’s breathing tube became detached and at what point staff should have suspected this had happened.

It would assess whether resuscitation efforts were adequate and whether it was necessary to call an ear, nose and throat specialist to the hospital to replace the tube.

The investigation would also examine communications between the hospital and the Fitzpatrick family at a number of meetings in the days following the incident.

The meetings were tense as Adam Fitzpatrick’s mother, a veterinarian, and sisters Amanda and Emma, ​​a paramedic and attorney respectively, used their expertise to challenge inconsistencies in the hospital’s version of events.

Rooney noted that the family is grappling with “deep loss, lingering fear and heartbreak” after losing Adam five days before his 21st birthday.

Fitzpatrick built a life in the NSW Riverina region and had big dreams for the future: “with a job he loved, life in a town he loved, with the girl he loved”.

“Every effort will be made over the next ten days to reconstruct what happened,” Rooney said.

During the hearing, Philippa recalled that Fitzpatrick was sometimes left unattended in the ICU when he was supposed to be receiving one-on-one care.


She recalled waking up from the sedation agitated and thrashing, and at one point his breathing tube – inserted through a hole in his throat known as a tracheostomy – became detached from the ventilator.

Nobody came, although the machine was alarming, and she had to reconnect the hose herself, Philippa said.

In the hours before Fitzpatrick went into cardiac arrest, Philippa recalled raising concerns with a doctor about the possibility of the breathing tube becoming detached while he was being weaned from the sedation.

“I thought it was sticking out at a weird angle,” Fitzpatrick recalled of the breathing tube. “It doesn’t sit flat against his skin.”

Jacques worked in the Intensive Care Unit at St George Hospital from 1989 until her retirement last November. She was the head of the unit at the time of Fitzpatrick’s death, but was not inducted into the area on the day of the emergency.

Jacques was asked if there were times when a patient who was supposed to receive individual care was not being monitored by a nurse.

“It is clear from the evidence that I have heard that there have been instances where there was no nurse in the room,” she said.

Jacques acknowledged that at the time she headed the department, staffing shortages meant that the doctors on duty did not always achieve the seniority levels they sought.

“This is in COVID and staffing has been a big challenge,” she said.

The investigation continues.

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Justin Scaccy

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